Journal of Dental Sciences 16 (2021) 1312e1314
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Perspective
Tooth preparation, digital design and milling
process considerations for CAD/CAM crowns:
Understanding the transition from analog to
digital workflow
Ilser Turkyilmaz a*, Gregory Neil Wilkins b, Giuseppe Varvara c
a
New York University College of Dentistry, Department of Prosthodontics, New York, NY, USA
b
New York University College of Dentistry, New York, NY, USA
c
Department of Medical, Oral and Biotechnological Sciences, Dental School, ‘G. D’Annunzio’
University of Chieti-Pescara, Chieti, Italy
Received 9 April 2021; Final revision received 11 April 2021
Available online 24 April 2021
KEYWORDS
CAD/CAM;
Crown;
Digital dentistry;
Milling;
Swirl marks;
Tooth preparation
In recent years, the transition from analog to digital work- ability to fabricate same-day restorations.1,2 At the fore-
flow has drastically increased in pace. The speed of this front of this revolution is the implementation of CAD/CAM
transition may be challenging for some faculty and dental technology to digitally design and mill restorations
students because of the steep learning curve associated with (Fig. 1A,B).3
technology and the requirement of practitioners to adopt a When fabricating ceramic restorations for CAD/CAM
new mind-set. Benefits of successfully implementing this production, the basic guidelines for tooth preparation are
new technology can include the reduction of overhead, an followed. Anterior teeth require a 2 mm incisal, 1.5 mm
increase in the predictability of restorative outcomes, and facial, and 1 mm lingual reduction while posterior teeth
require a 2 mm occlusal and 1.5 mm axial reduction. For
both anterior and posterior teeth, a uniform chamfer
margin of 1 mm must be placed 360 around the tooth,
* Corresponding author. New York University College of Dentistry, prepared walls must be smooth, internal line angles must
Department of Prosthodontics, 380 Second Avenue, Suite 302, New be rounded, and the preparation should be absent of un-
York, NY, 10010, USA. dercuts. In addition to these basic preparation
E-mail address: ilserturkyilmaz@yahoo.com (I. Turkyilmaz).
https://doi.org/10.1016/j.jds.2021.04.005
1991-7902/ª 2021 Association for Dental Sciences of the Republic of China. Publishing services by Elsevier B.V. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Journal of Dental Sciences 16 (2021) 1312e1314
Figure 1 Digital workflow of the CAD/CAM crown. (A) Digital impression of the prepared tooth. (B) Digital design of proposed
restoration. (C) Swirl marks on the internal surface indicating overmilling. (D, E, F, G, H, and I) Cross-sectional views of the
prepared tooth, proposed restoration and overmilled areas.
characteristics, CAD/CAM restorations require supplemen- molten material during investing and casting steps. Though
tary refinements to ensure compatibility with the selected not ideal, analog methods can allow for a narrower
milling unit. Anterior teeth, especially incisors, are an area (<1 mm) incisal edge to be fabricated with more promising
where CAD/CAM milled restoration failures occur in high results unlike CAD/CAM digital techniques. When using
frequency. These teeth are taller and narrower than pos- these new technologies, one must be familiar with their
terior teeth and require additional incisal edge thickness restrictions to produce successful restorations.
(faciolingually) of at least 1 mm to accurately reproduce CAD/CAM milling deficiencies can be circumvented in
the preparation for the intaglio surface of the restoration. many ways, most involving a wholistic restorative approach
Posterior teeth must also be refined to have flatter and to yield successful treatment. Clinicians may lessen the
broader 1 mm cusps to reduce the loss of excess material probability of failure due to overmilling by being mindful of
from CAD/CAM milling limitations. tooth preparation proportions and the milling machine’s
These refinements are implemented to counteract CAD/ bur shape/diameter. Clinicians may also be more meticu-
CAM overmilling, or the excess removal of material on the lous during the mill simulation step of fabrication
internal surface of CAD/CAM milled restorations. Over- (Fig. 1CeI). Checking the internal surface for swirl marks
milling is a result of a milling machine’s dimensional limi- (the preliminary sign of overmilling) before milling begins
tations caused by the size of its burs. Standard bur sizes in may allow time for preparation refinement, crown adjust-
milling machines are normally 1.8 mm in diameter for the ment (increase thickness, modify contours), or a change in
cylinder-pointed bur (external surface) and 1 mm or 1.3 mm the type of restorative material (composite resin with
in diameter for the step bur (internal surface). The ceramic filler particlesc, zirconia). Milling machines with
consequence of points on the internal surface of the higher axis count should also be considered to yield the
restoration that are narrower (<1 mm) than these mea- most accurate results.
surements is overmilling. This excess reduction results in The use of multi-axis milling machines has increased the
material thinning and ultimately restorative failure. effectiveness of CAD/CAM dentistry by increasing the ac-
One of digital technology’s main benefits is its ability to curacy of restorations, delivering them in a shorter period
streamline formerly time-consuming analog processes. of time, and increasing patient satisfaction. However, they
Labor intensive processes such as fabricating framework inherently have some limitations such as the size, cost, and
and metal components for porcelain fused to metal pros- type of milling machine (4-axis or 5-axis).4 These charac-
thesis via lost-wax techniques can be expedited. The mul- teristics all contribute to how valuable of an asset a clini-
tiple steps (waxing, investing, burnout, casting) of these cian deems their milling machine. While size and cost are
prolonged methods can now be performed in a fraction of important, the number of axis plays the most important
the time by using digital scanning, CAD/CAM fabricating, role in restorative accuracy. Milling machines that have an
and milling technologies. Dimensional limitations are not increased number of axis are able to experience more ac-
seen by analog methods because of flowable nature of curate cutting because of their increased ability to move. In
1313
I. Turkyilmaz, G.N. Wilkins and G. Varvara
dentistry, 5-axis machines offer the most freedom to move Acknowledgments
making them capable of producing accurate restorations in
a shorter amount of time. This high degree of movement This work is not supported by any grants from any
also reduces the chances to produce “swirl marks”, institutions.
resulting in more successful restorations with less
overmilling.
A major threat to clinicians wishing to seek the benefits
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